Coronavirus patients who are severely ill often need someone to make care decisions on their behalf.
During the coronavirus disease 2019 (COVID-19) pandemic, it is critically important for people to have healthcare proxies, a palliative care expert says.
People can assign someone to serve as a healthcare proxy when they are unable to make care decisions on their own. This arrangement is essential during the coronavirus pandemic for patients and their caregivers because treatment for severe COVID-19 cases involves mechanical ventilation and sedation.
Healthcare organizations should encourage their patients to have healthcare proxy documents, says Kosha Thakore, MD, director of palliative care services at Newton-Wellesley Hospital in Newton, Massachusetts.
"Even outside of COVID-19, it should be standard of care for us to approach patients about having a healthcare proxy because it allows us to take much better care of patients. It is heightened in the age of COVID-19 because what we are seeing are conversations about who patients want to make decisions on their behalf and who can speak to their values and goals," she says.
A healthcare proxy can play an essential role in COVID-19 critical care, Thakore says.
"There are people with COVID-19 who are at very high risk of having poor outcomes. So, we need to start having conversations as early as we can about a patient's values and goals. You need to have a conversation about which interventions really meet a patient's values and goals if they are not going to result in the patient having a good quality of life or an ability to continue being independent. These are the types of conversations we are needing to have urgently in a crisis."
Critical care interventions may not be in a patient's best interest and healthcare proxies can make these kinds of decisions when patients are incapacitated, she says. "Sometimes, putting a patient through intensive care is not going to accomplish the patient's goals, so we need to have conversations with people to avoid doing care that may not be beneficial to patients and may harm them."
The absence of a healthcare proxy can place care teams in an extremely difficult situation, Thakore says.
"The laws for this situation vary from state to state. In Massachusetts, how decisions are made is based on the imminence of the patient's condition. If the patient is in an imminent state, and the attending physician and another physician both feel critical care would be futile—it would not result in prolonging life or saving the patient—then it is up to the discretion of the attending physician to make a decision in the moment."
For incapacitated Massachusetts patients who do not have a healthcare proxy and are not in an imminent medical state, a hospital must go to the courts and petition for a guardian to make decisions on the patient's behalf, she says. "This can result in significant delays in care and misuse of medical resources. Under those circumstances, the patient can be in limbo for several weeks."
How healthcare proxy arrangements work
In Massachusetts, healthcare proxy documentation is relatively straightforward and does not require the assistance of an attorney, Thakore says. The basic elements of a healthcare proxy document are the identifying information of the patient—their full name and their date of birth—then the designation of someone to make decisions on the patient's behalf if they are unable to make decisions.
"At minimum, you need one person to be a proxy; but, ideally, you should select one person and an alternate in case the first person can't make decisions on your behalf. Then you need the signature of the patient and two witnesses—neither of whom can be listed as a proxy on the document," she says.
Once a proxy form has been completed, it should be entered into the patient's medical record, Thakore says.
"In our health system, you supply the form to your primary care physician, then the document is scanned into the electronic medical record so it can be accessed by all providers. If the document is completed in the hospital, we also scan it into the electronic medical record."
As long as a patient is fit to make medical decisions, it is never too late to complete healthcare proxy documentation, she says.
"If patients are in the ER and can speak for themselves, then you can address a proxy document in a somewhat urgent manner. Whenever someone enters our ER, they receive a screening question about whether they have a healthcare proxy. When we get into trouble is if someone without a proxy comes into the hospital and they are no longer able to make decisions for themselves."
Establishing a healthcare proxy should not be a stressful process, Thakore says.
"It is about encouraging conversations between patients and their loved ones about what matters most to them, their goals, and quality of life. Ultimately, what a proxy document does is give a gift to your loved ones so they know what decisions you want made on your behalf if there is a situation where you can't make your own decisions. It is like insurance. We hope we never have to use it, but it is always good to have."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Coronavirus infections can be incapacitating when severely ill patients are sedated and placed on mechanical ventilation.
A healthcare proxy document assigns someone to make care decisions on a patient's behalf when they are incapacitated.
The absence of a healthcare proxy can put critical care teams in extremely difficult situations, where they can be forced to make life-or-death decisions on a patient's behalf.